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MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 626.557, subdivision 1 states, “The legislature declares that the public policy of this state is to protect adults who, because of physical or mental disability or dependency on institutional services, are particularly vulnerable to maltreatment.”
License Number and Program Type: 1072149-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lindsay Arth/Beth Virden Suspected Maltreatment Reported: It was reported that staff did not intervene when a vulnerable adult (VA) had contact with a community person (CP), who was on the Minnesota sex offender registry; when the VA felt unsafe with his/her housemate (H); and when, more than once, the VA slept on a mattress on a garage floor. Date of Incident(s): Ongoing prior to November 20, 2025 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 17, paragraph (a): The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on December 5, 2025; from documentation at the facility and law enforcement records; and through nine interviews conducted with the VA, the VA’s guardians (G1 and G2), the VA’s case manager (CM), an adult protective services worker (APS), facility staff persons (P1-P3), and a supervisory staff person (P4). The VA’s support plans, including Self-Management Assessment and Individual Abuse Prevention Plan, stated the following: · In May 2024, the VA moved into the facility seeking services and support relating to his/her diagnoses, which included intellectual disability. The VA had a history of declining medications; ordering inappropriate things from the internet, like an expensive chinchilla; being “[boy/girl] crazy”; running into traffic; and experiencing poor impulse control and chronic and frequent emotional outbursts. · The VA required the presence of an awake staff person at the facility 24/7 and had 1:1 staff 12 hours per day on weekdays and eight hours per day on weekends. Staff persons were to conduct “60-minute safety checks,” “1:1 time and monitoring [the VA’s] whereabouts … on and off the property throughout the day.” If the VA did not return to the facility in 30 minutes, staff were to notify the guardians and law enforcement. [Note: The records reviewed for this investigation did not provide additional details about the VA’s supervision requirements for the times s/he did not have a 1:1 staff; for the VA’s community supervision requirements; and/or for how staff were to monitor the VA’s whereabouts or conduct 60-minute safety checks.] The facility was a single-family home where the VA lived with his/her housemates. The facility provided staff for the VA’s and his/her housemates’ care and supervision. Facility documentation stated that P1-P4 received training on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act. Regarding the VA’s interactions with the CP: The VA’s Individual Abuse Prevention Plan and Rights Restriction, each dated June 23, 2025, stated the following: · The VA had a history of giving out personal information and trusting people “very easily.” “[The VA] is very friendly to people, and trusts people to the point where [s/he] is putting [him/herself] in harm's way by not knowing the kind of people [s/he] is befriending.” The VA might seek or cooperate in an abusive situation or risky sexual behavior. · The VA “was in a relationship” with the CP, who was a “level 3 sex offender.” [Note: The CP was listed on the Minnesota sex offender registry.] “[The VA] did not understand how this was a dangerous situation.” The VA had a history of leaving without staff knowledge or supervision and more than once was discovered at the CP’s house or at a park with the CP. If staff discovered that the VA left, they were to search for the VA and contact the police and G1 and G2 if they were unable to locate with VA within 30 minutes. · The VA’s right to associate with people of his/her choosing and right to engage in chosen activities were restricted to ensure his/her health, safety, and wellbeing. The VA was not allowed to access electronics and the internet. Staff monitored the VA’s phone calls to ensure s/he did not contact the CP or the VA’s family member (FM) “who [the VA] is legally not able to contact.” The APS said that on October 29, 2025, the VA told him/her that s/he sometimes met up with the CP and that the CP was the VA’s “[boy/girlfriend].” The VA said that s/he and the CP “dated” between May and October 2025. [Note: On October 28, 2025, the VA was interviewed by a professional who specialized in interviewing children and vulnerable adults who were alleged to be victims of sexual abuse. The VA told the interviewer that s/he and the CP cuddled, hugged, and kissed, but declined to answer additional questions about his/her relationship with the CP. A law enforcement officer referred the information to a county attorney for review of criminal charges against the CP and that review was pending.] G2 said that the VA met the CP while at a doctor’s appointment where they exchanged phone numbers. Staff waited in the lobby for the VA when s/he attended medical appointments. G2 was trying to pursue criminal charges against the FM because the FM, more than once, picked the VA up and took him/her to see the CP. The FM facilitated the VA meeting up with the CP. The CP’s probation officer (PO) had previously told the CP to cease communication with the VA. This, along with information that the VA had been randomly messaging people to visit him/her, resulted in the team restricting the VA’s right to access the internet and required staff to monitor the VA’s phone calls. P1-P4 provided the following information: · P4 said that the VA most likely met the CP around May 2025, but the VA was “very secretive” at first about their relationship and was most likely communicating with the CP with a hidden cellphone. The VA was not allowed to have a cellphone, but at one point, staff found a cellphone hidden in the facility’s garage, which they believed belonged to the VA. It was unknown how or when the VA got the cellphone, but the FM had a history of giving him/her “a lot of stuff.” The VA was not supposed to have contact with the FM but more than once, the FM drove up to the facility and the VA jumped in their car before staff were able to intervene. More than once, the FM brought the VA to see the CP. Staff called 9-1-1 when they saw the VA jump into the FM’s car. · P1 and P3 both said that they saw the CP at the facility one time, each. P1 said that this was “during the summer” of 2025. P1 and P3 did not immediately know who the CP was, and the VA told staff that the CP was the VA’s sibling. The VA and the CP stayed in the garage sitting on lawn chairs and talking, and P1 and P3 had no concerns with their interactions. When P4 told staff that the CP was not allowed at the facility, P3 never saw the CP again. P1 said that one time the VA commented that the CP was heading over and P1 immediately called P4, who said that if the CP stepped on the facility’s property, P1 should call 9-1-1. When the CP arrived, P1 told the CP to leave, and s/he did without incident. · P2 said that twice, s/he went to a park with the VA and the VA started walking around with the CP while P2 followed behind. The VA told P2 that the CP was a “friend.” When P4 told P2 that the VA should not have contact with the CP, P2 never saw the CP again. · P4 said that on an unknown date, the VA invited the CP to the facility for a visit and told P4 that the CP was the VA’s sibling; however, P4 knew that the CP was not the VA’s sibling and that “something seemed off.” P4 searched the internet for the CP’s name and discovered s/he was a registered sex offender. P4 immediately told the CP to leave the facility and contacted the PO. The PO acted “fast” and “days later,” the CP was “gone.” [Note: The CP’s probation was revoked, and s/he returned to prison. It was unclear if the CP’s probation violation was specific to his/her contact with the VA and/or for other reasons.] Around mid-October 2025, the CP was released from prison and again visited the facility. This time, staff immediately called 9-1-1 and the PO, and the CP left without incident. [Note: At the time of this investigation, the CP’s probation was again revoked, and s/he was back in prison.] P4 added that more than once, the FM picked the VA up and brought him/her to the CP’s house and when this occurred, staff called 9-1-1 and the PO. Law enforcement records stated the following: · On April 24 and July 1, 2025, a staff person called 9-1-1 reporting that the VA’s family member had driven away with the VA without staff supervision or awareness of where they were going. The law enforcement officers (LEO) contacted the family member who agreed to bring the VA back to the facility. · On June 12, 2025, a staff person called 9-1-1 reporting that the VA was destroying property and wanting to kill him/herself. Staff told the LEO that the VA had threatened the PO. The LEO transported the VA to a hospital for evaluation. [Note: Information was provided that the VA threatened the PO because the PO had restricted the CP’s contact with the VA.] · On June 29 and July 4, 2025, a staff person called 9-1-1 reporting that the VA had contact with an unspecified person, which was a violation of a court order. The VA’s medical records stated that during a routine appointment on October 8, 2025, the VA told healthcare professionals that s/he was “grieving the loss of a past relationship,” but did not provide additional detail. On October 20, 2025, the VA told healthcare professionals that s/he had not engaged in any sexual activity for “several months” and that s/he did not have any concerns for his/her safety. The facility’s Incident Report stated that on October 22, 2025, around 12:30 p.m., the VA jumped into the FM’s truck, and the FM drove away without staff supervision. The VA’s housemate told staff that the VA had reconnected with the CP, who was released from prison. Staff called the PO, who used the CP’s electronic monitoring system to locate the CP. Staff drove to the location and found the VA and the CP together in a bookstore. The VA ran when s/he saw the staff and jumped back into the FM’s truck. Staff called the FM, who agreed to drive the VA back to the facility with staff following behind in their car. The VA returned to the facility unharmed, and the CP was “arrested” by the PO. [Note: The facility provided daily shift notes for “incidents” and there was nothing provided that the VA left without supervision between July 4 and October 22, 2025.] Regarding the VA’s interactions with the H: The VA said that the H threatened to punch and kill him/her, which made the VA “afraid,” and when this occurred, the VA made unspecified comments back to the H or did not respond. There was never any physical aggression. The APS, the CM, G1, G2, and P1-P4 each said that the VA told them that s/he was “afraid” of the H and/or that the H made “threats” to harm the VA. G1, G2, and P1-P4 witnessed arguments between the two but never heard threats of violence and had no information of physical aggression or harm. The VA was “vibrant” and “loud,” which “agitated” the H. Staff were always present and saw the VA ignore the H’s comments or walk away. G2 said that s/he heard staff tell the VA and the H to walk away from one another. Law enforcement records stated that between July and October 2025, eight calls were placed to 9-1-1 requesting law enforcement assistance for a “confrontation” between the VA and an unspecified housemate. There was yelling and name-calling but no reports of physical violence. Each incident was cleared by law enforcement with no further action taken, and the VA and the housemate agreed to stay away from each other. Regarding the VA sleeping on a mattress on the facility’s garage floor: The VA said that there was a mattress on the facility’s garage floor, which s/he liked to sleep on. The VA typically brought blankets and stuffed animals with him/her to the mattress. Some staff told the VA to return inside, and some staff did nothing. G1 and G2 told the VA to stop sleeping in the garage and removed the mattress from the garage. The APS said that on October 29, 2025, s/he went to the facility and saw a mattress on the garage floor, which the VA later told the APS that s/he sometimes slept on. The CM said that s/he was not aware of the VA sleeping in the garage but said that if this occurred, the CM “wouldn’t be okay with that.” At times, the VA might choose to sleep on the living room couch. G1 and G2 each said that the VA repeatedly wanted to sleep in the garage. Staff and G2 told the VA that s/he could not sleep in the garage, but the VA seemed to find a way to sleep there anyhow. The VA refused to sleep on his/her bed in his/her bedroom. P1-P4 each said that the VA did not like sleeping in his/her bedroom. The VA typically slept on the living room couch but when s/he was “upset” or needed space, s/he might go out to the garage where s/he fell asleep on the mattress in the garage. The VA never slept on the mattress all night. The VA might lay on the mattress during the day for less than 20 minutes at a time. Staff told the VA that it was not clean or safe to sleep in the garage and encouraged the VA to return inside but they could “not force” him/her back inside. P2 typically sat with the VA when the VA was in the garage. The VA did not sustain injuries (e.g., frostbite, heat exhaustion) and the mattress was since removed. Regarding the VA’s overall supervision: The facility was in a residential neighborhood surrounded by other residential homes, including a house next door, which was owned and operated by the same license holder and provided staff for the clients who lived there. Some staff were cross trained to work at the facility and the house next door. The APS said that s/he was familiar with the VA through various interactions and was aware that the facility should be providing the VA with a 1:1 staff person. However, during 2024 and 2025, the APS visited the facility five different times, at unspecified dates and times, and each time, there was not a 1:1 staff person for the VA. During the APS’s most recent visit to the facility, on October 29, 2025, at an unspecified time, the VA did not have a 1:1 staff and the staff, who was working, did not know the VA’s whereabouts. The VA was not at the facility. The staff searched and eventually located the VA at the house next door, unharmed. The VA said that s/he routinely went to the house next door to hang out with other clients and his/her 1:1 staff did not go with him/her. The facility did not always provide a 1:1 staff for the VA. The CM said that the VA’s history with “elopement was always a concern.” The VA might give his/her address to strangers and was “sneaky” and might have someone pick him/her up down the street. The VA was “extremely vulnerable” and “very childlike,” “needed supervision,” and did not have any “alone time.” The VA told the CM that there were days the facility did not provide a 1:1 staff for him/her. There was one day in September 2025 when the facility notified the CM that they had a staffing shortage and were unable to provide the VA’s 1:1 staff on that day. This was the sole time the facility notified the CM of such an occurrence. Staff should “always (be) present” with the VA. G1 said that s/he and G2 “okayed” the VA to go to the house next door without a facility staff person and instead, the facility staff person might periodically check on the VA next door, might stay with him/her for a time, or might go “back and forth” between the houses. G2 said that the facility should provide the VA with a 1:1 staff during certain hours of the day; however, the facility went through periods of “staffing problems,” and “There have been times that they [the facility] don’t have [a 1:1 staff for the VA].” P1-P4 provided the following information: · P1-P3 provided consistent information that “every day” the VA left the facility without telling staff and walked to the house next door. The VA spent hours next door hanging out and chatting with the clients who lived there. P1 and P3 each said that they typically stayed at the facility when the VA left and texted the staff next-door that the VA was heading over and asked to be notified when the VA was headed back to the facility. The staff next door then watched (supervised) the VA on behalf of the facility staff. P2 typically followed the VA next door or waited at the facility for 15 to 20 minutes before going next door to check on the VA. P2 might also go next door to check on the VA and the VA will, in turn, run back to the facility away from P2. P1-P3 encouraged the VA to return to the facility when s/he was next door, but the VA would typically refuse until s/he eventually returned on his/her own accord. · P4 said that staff should follow the VA when s/he went next door. However, typically when staff followed the VA next door, the VA would immediately return to the facility and when the staff came back to the facility, the VA would turn around and return to the house next door. “It’s kinda like a cat and mouse game throughout the day.” There were typically two staff working next door, who were also trained on the VA’s support plans. More than once when there was a staffing shortage at the facility and P4 was the sole staff working at the facility, when the VA went next door, P4 texted the staff next door and asked them to supervise the VA. The VA’s interdisciplinary team (e.g., guardians, case manager) was aware of the staffing shortage issue. · P4 said that the facility provided the VA with a 1:1 staff each day; however, the times of day might vary. If staffing was short in the mornings, P4 “tried to make [the 1:1 staffing] up in the evenings.” The VA was the sole client with a 1:1 staff requirement; the other clients had “unlimited alone time.” P4 added that the VA could be “alone” (unsupervised) during his/her 12+ hours each day without a 1:1 staff, but staff needed to know his/her whereabouts and “make eyes on” him/her. [Note: As previously stated above there was no information in the VA’s plans regarding the VA’s supervision outside of the 1:1 or while in the community.] The VA had a history of running to the park with staff running behind and the VA did not like this and wanted “time alone.” At one of the VA’s interdisciplinary team meetings (unstated when this occurred or who was in attendance), “They said, ‘Okay, if [the VA] wants to take [his/her] walk up to the park, [s/he] just needs to let staff know where [s/he] is going and check-in (in) 20 to 30 minutes. If [s/he] doesn’t check-in then [staff] go looking, and so, that was kind of what went on for quite some time, and s/he’d come back, and then when s/he met [the CP] is when like [s/he] did it more and was sneaky about it and wasn’t telling us.” The VA would say that s/he was going to the park but when staff went looking, they’d find him/her at the gas station. [Note: The VA’s support plans, reviewed for this investigation, did not provide information about the VA walking to the park unsupervised and checking-in with staff in 20 to 30 minutes.] · P2 said that the VA might run to the park. “Sometimes, I follow and kind of watch from far away … I try to stick with [him/her] because it’s part of my job.” · P3 said that the VA could be outside without staff if staff were checking on him/her. The VA used to run to the park when s/he was “upset.” P3 did not know why the VA had 1:1 staffing but said that there were times staff were unavailable to work and so the VA did not receive a 1:1 staff as required. · P1 said that the VA did not have any “alone time.” · P1-P4 each had no information the VA sustained injuries or harm from being at the house next door or from being without a 1:1 staff person as required. The facility’s incident report and law enforcement records each stated that on March 17, 2025, the VA called 9-1-1 stating that there were no staff at the facility. The LEO responded and confirmed that there were no staff at the facility. At an unknown time later, a staff person arrived at the facility after having been at the house next door. It was not stated how long the VA was unsupervised and there was no information of any harm to the VA from this incident. Relevant Minnesota Statutes and Rules: Minnesota Statutes, section 245D.07, subdivision 1a, which states, in part, the license holder must provide services in response to a person’s identified needs, interests, preferences, and desired outcomes as specified in the support plan and the support plan addendum as required. Minnesota Statues, Section 245D.081, subdivision 2, which states, in part, the license holder must ensure that the service delivery for each person was coordinated by a designated staff person as required. Conclusion: A. Maltreatment: Regarding the VA’s interactions with a community person (CP) who was a registered sex offender: More than once, the VA saw or had contact with the CP. At first staff did not know who the CP was and so did not immediately intervene and also did not have concerns about their interactions. Once P4 told staff that the CP was not allowed to contact the VA, staff told the CP to leave when s/he arrived and called the police and the PO and/or never saw the CP again. However, the VA’s family members provided him/her with an unauthorized cellphone and brought the VA to the CP’s house, and when staff discovered these incidents, they intervened. Despite the VA’s repeated interactions with the CP, there was not a preponderance of evidence whether the facility should have or could have done more to prevent the contact and/or whether the conduct included a failure to supply the VA with care or services, which were reasonable and necessary to maintain the VA’s physical or mental health or safety. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Regarding the VA’s interactions with his/her housemate (H): The VA said that the s/he was “afraid” of the H, who made threats to kill him/her. Given that no one else heard these threats but that, instead, staff witnessed incidents when the VA and the H argued and then walked away from one another and that there was no information of any physical aggression, there was not a preponderance of the evidence whether there was a failure to supply the VA with care or services, which were reasonable and necessary to maintain the VA’s physical or mental health or safety. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Regarding the VA sleeping on a mattress on a garage floor: The VA said that s/he slept on a mattress on the garage floor. Staff provided consistent information that the VA might hang out or lay on the mattress and fall asleep but that s/he did not sleep on the mattress all night and instead, typically slept on the living room couch at night. Given that staff encouraged the VA to return inside but could not force the VA back inside and that the VA never sustained injury from laying on the mattress, there was not a preponderance of the evidence whether there was a failure to supply the VA with care or services, which were reasonable and necessary to maintain the VA’s physical or mental health or safety. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Regarding the VA’s overall supervision: The VA’s support plan and the support plan addendum stated that the VA required the presence of an awake staff person at the facility 24/7 and had 1:1 staff 12 hours per day on weekdays and eight hours per day on weekends. Staff persons were to conduct “60-minute safety checks,” “1:1 time and monitoring [the VA’s] whereabouts … on and off the property throughout the day.” If the VA did not return to the facility in 30 minutes, staff were to notify the guardians and law enforcement. The records reviewed for this investigation did not provide additional details about the VA’s supervision requirements for the times s/he did not have a 1:1 staff; for the VA’s community supervision requirements; and/or for how staff were to monitor the VA’s whereabouts or conduct 60-minute safety checks. The VA, G1, G2, the CM, the APS, and staff provided consistent information that the facility did not always provide a 1:1 staff for the VA as required and at times, the staff working did not know the VA’s whereabouts. This conduct was inconsistent with the VA’s identified needs as specified in his/her support plan and the support plan addendum and a violation of Minnesota Statutes, section 245D.07, subdivision 1a; and Minnesota Statues, Section 245D.081, subdivision 2. The VA, G1, the CM, and staff provided inconsistent and conflicting information regarding the VA’s supervision requirements. P1-P3 each said that when the VA went next door, staff did not always follow him/her. P4 said that staff should follow the VA next door. G1 said that s/he and G2 “okayed” the VA to go to the house next door without a facility staff person. P4 said that the VA could go to the park unsupervised if s/he checked-in with staff within 20 to 30 minutes. P2 said that s/he “sometimes” followed the VA to the park. P3 said that the VA could be outside unsupervised if staff checked on him/her. P1 and the CM each said that the VA should not be unsupervised. The VA had a history of leaving without a staff person’s knowledge and/or supervision, running into traffic, and experiencing poor impulse control and chronic and frequent emotional outbursts. The VA was also susceptible to sexual abuse and had a well-documented history of trusting people “very easily” and being “very friendly … to the point where [s/he] is putting [him/herself] in harm's way.” However, despite the VA’s history and vulnerabilities, the overall provision of the VA’s supervision was inconsistent, conflicting, and unclear among staff and in the VA’s support plans which allowed the VA repeated, unsupervised interactions with a registered sex offender; and the VA to leave the facility “every day,” including walking between the facility and the house next door, without a staff person always watching and/or always knowing the VA’s whereabouts, which represented a substantial risk of harm to the VA. Therefore, there was a preponderance of the evidence that there was a failure to supply the VA with care or services, which were reasonable and necessary to maintain the VA’s physical or mental health or safety. It was determined that neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. P1-P4 were each responsible for the VA’s care and supervision, and received training on the VA’s support plans and the Reporting of Maltreatment of Vulnerable Adults Act. Given that P1-P4 represented varying supervisory roles and levels of authority within the facility, and given that the VA’s support plans, which lacked necessary information, were largely created and/or approved by supervisory or administrative staff persons, P1’s-P4’s individual responsibilities were mitigated and instead, there was a systemic failure by the facility. The facility was responsible for maltreatment of the VA. C. Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated maltreatment for which the facility was responsible did not meet statutory criteria to be determined as serious. The VA did not sustain a serious injury. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and followed. The VA had a history of making connections with people in the community, who the VA did not know, and leaving without supervision. The facility did not determine a need for additional training or corrective action at this time. Action Taken by Department of Human Services, Office of Inspector General: On March 4, 2026, the license holder was ordered to forfeit a fine of $1000 as a result of the substantiated maltreatment for which facility was responsible. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal. A copy of this report was forwarded to the Office of Inspector General-Program Integrity Oversight Division for their review of possible financial fraud.
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